License Request 1/9/23

Date

Full Name:*

First NameLast Name

Address:*

Street Address

Street Address Line 2

City

Zip Code

Phone:*

Area CodePhone Number

Alternative Phone:

Area CodePhone Number

E-mail:*

Is this a NEW License, RENEWAL License or Change in Status?*

NewRenewalChange in Status (Pet Deceased, Rehomed, etc)Tag Replacement (current license was lost, damaged, etc).

Current License Number:

Is this a Late/Past Due License Renewal? (Honesty is the best policy.)*

Yes - Add $20 late feeNo

Do you physically have the tag for the license that you are requesting to renew?*

Yes I still have the tag. I do NOT need a replacement tag.No, I no longer have the tag (lost, damaged, etc) and I WILL NEED a replacement.

Please note that the first tag replacement is complimentary,
however there will be a $10 fee for additional replacement tags.

Is this the first tag replacement you have requested for this pet? (Honesty is the best policy.)*

YesNo

License Expiration Date

Date

Pet's Name:*

Breed*

Is your Dog Spayed or Neutered?*

Spayed/NeuteredNOT Spayed/Neutered

Specify reason for status change:*

MovedPet is deceasedPet has been rehomed

Please upload a current signed Rabies Certificate:*

Upload a File

Date of Rabies Vaccination:*

Date

Date Rabies Vaccination Expires:*

Date

Calculation

Your pet is due for an updated Rabies vaccine in 30 days or less. You are not currently eligible to purchase a license at this time. Please contact your veterinary office to schedule to get your pet a Rabies vaccine before you apply for a license.

Thank you!

1 Year Eligibility for Sterilized Dog:

1 Year Spayed/Neutered License Fee $10

1 Year Eligibility for Unaltered Dog:

1 Year Unaltered License Fee $30

1 or 2 Year Eligibility for Sterilized Dog:

1 Year Spayed/Neutered License Fee $102 Year Spayed/Neutered License Fee $18

1 or 2 Year Eligibility for Unaltered Dog:

1 Year Unaltered License Fee $302 Year Unaltered License Fee $55

1, 2 or 3 Year Eligibility for Sterilized Dog:

1 Year Spayed/Neutered License Fee $102 Year Spayed/Neutered License Fee $183 Year Spayed/Neutered License Fee $25

1, 2 or 3 Year Eligibility for Unaltered Dog:

1 Year Spayed/Neutered License Fee $302 Year Spayed/Neutered License Fee $553 Year Spayed/Neutered License Fee $75

License Fee*

Tag Fee

Square Processing Fee

API Fee

Total Processing

Processing Fee

TOTAL*

Notes:

Payment*

USDLicense Fee

Credit Card

Licensing Request

Credit Card